dentists - 2021 schedule of dental services and fees for

DentistsSchedule of Dental Services and Fees for Ontario Works Adults

2021

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2021Ontario Works Adults - Schedule of Dental Services and Fees

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PURPOSE OF THE PROGRAM

Halton Region does not intend to provide on-going regular dental care to adults in the Ontario Works (OW) program. The OW Adults dental program is not an insurance plan. This program provides three types of care:

• Emergency care for conditions involving pain, infection, or trauma.• Denture care to restore chewing ability and/or speech.• Non-emergency dental services will only be covered under special circumstances.

WHO IS ELIGIBLE?

• Adults who are currently on OW.• Confirmation must be received by the dental office from the Health Department via telephone or the Ontario Works Adults –

dental claim form.• If treatment is not occurring during business hours, the dental office must call Halton Region on the next business day.

Business hours are 8:30 a.m. to 4:30 p.m., Monday to Friday.• Should more treatment be required past the expiry date, contact Halton Region to re-verify eligibility.• Only residents of Halton Region are eligible.

DENTAL EMERGENCIES

Adults in the OW program, with a dental emergency, can be seen by a dental treatment provider immediately. A dental emergency involves pain, infection or trauma.

If treatment is not occurring during business hours, the dental office must call Halton Region on the next business day. Business hours are 8:30 a.m. to 4:30 p.m., Monday to Friday.

NON-EMERGENCIES

Adults with non-emergency dental conditions must first be screened by Halton Region Oral Health staff. To schedule a screening appointment, please call Halton Region at 905-825-6000.

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2021 Ontario Works Adults - Schedule of Dental Services and Fees

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DENTAL TREATMENT PROVIDER’S ROLE

The provider determines the treatment needs for OW Adults clients and will submit claims according to the OW Adults schedule of fees.

• For emergency care up to a maximum of $200.00, the provider may treat the urgent need and submit a claim form, providedthat the fee schedule does not indicate pre-determination is required (please see note below).

• For non-emergency care, the provider must submit a treatment plan to Oral Health at Halton Region prior to beginningtreatment.

Note: Some services require pre-determination prior to service provision. These services are marked with a “P” beside the procedure code. For these services, providers must forward a pre-determination and information, as indicated in the Ontario Works Adults - Schedule of Dental Services and Fees or as requested by Halton Region Oral Health.

FEE LEVELS

The fees listed in this schedule are the maximum fees for the covered services. Dental treatment providers who accept clients under this fund agree to provide the covered services for the specified fees only. The fees constitute full payment for services, and there is no balance-billing or extra-billing to the client for covered services.

For services provided by registered dental specialists, specialist fees are given.

LABORATORY FEES

A copy of the laboratory invoice(s) must accompany the claim form.

FUNDING

This program is funded by Halton Region’s Social & Community Services Department, and is administered by the Halton Region Health Department, Oral Health.

BILLING CODES RELATED to COVID-19

Effective November 1 2020, the following billing codes have been added to the OWA Fee Guides. Please note the specific parameters for these billing codes:

Code Description Parameter99900 Provision of additional personal protective

equipment required by the COVID-19 pandemic

• Use of regular PPE is not eligible for billing• A flat fee within the fee guides, per appointment

05201 Consultation with Patient • Specific to tele-dentistry, only during a declaredStage 1 Provincial Emergency where dentalclinics are unable to be open due to thedeclared emergency

• A maximum of one unit of time per appointment

LETTER OF EXPERTISE For certain services, a letter of expertise (LOE) must accompany the pre-determination. The need for a LOE is indicated in the "Limit" column of the fee schedule. The LOE should provide information which supports the need for coverage of this service for this patient.

The LOE should be submitted on office letterhead and be signed by the dental treatment provider. The letter must include: patient's name; date of birth; name of dental treatment provider; and office address. It may include the following information: clinical findings; diagnosis; prognosis if treatment is provided; prognosis if treatment is not provided; and impact of treatment/non-treatment on the patient's ability to function. The LOE may include radiographs if available.

OTHER INFORMATION

If you have additional questions about this fund please contact Halton Region at 905-825-6000.

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2021Ontario Works Adults - Schedule of Dental Services and Fees

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Dentists - Ontario Works Adults Fee Guide - 2021 1 of 18

Ontario Works Adults - Schedule of Dental Services & Fees - 2021

Code Description P General Specialist Limit

Diagnostic ServicesEXAMINATIONExamination and Diagnosis, Complete Oral, to include:a) History, Medical and Dentalb) Clinical Examination and Diagnosis of Hard and Soft tissues, including carious lesions, missing teeth, determination of pocketdepth and location of periodontal pockets, gingival contours, mobility of teeth, interproximal tooth contact relationships, occlusion ofteeth, TMJ, pulp vitality tests/analysis, where necessary and any other pertinent factors.c) Radiographs extra, as required.

01103 Examination and Diagnosis, Complete, Permanent Dentition to include:(a) Extended examination and diagnosis on permanent dentition, recording history, charting,treatment planning and case presentation, including above description

P $ 83. 59 $ 100. 31 1 per 60 months, per patient, per dental treatment provider, per dental office address.

01204 Examination and Diagnosis, SpecificExamination and evaluation of a specific situation

$ 20. 89 $ 25. 07 1 per 12 months, per patient, per dental treatment provider, per dental office address.

01205 Examination and Diagnosis, EmergencyExamination and diagnosis for the investigation of discomfort and/or infection in a localized area

$ 20. 89 $ 25. 07 All emergency exams will be covered.

05201 Consultation with Patient $ 16. 12 $ 19. 34 Specific to tele-dentistry during a declared Stage 1 Provincial Emergency where dental clinics are unable to be open due to the declared emergency.Request for payment of this code outside of any declared Stage 1 Provincial emergency will be declined.

A maximum of one unit of time per appointment.

RADIOGRAPHS(Including Radiographic Examination and Diagnosis and Interpretation)

Maximum of 5 periapical films per 12 months, per patient, per dental treatment provider, per dental office address (except when required in an emergency situation) are paid cumulatively.

Maximum payable for periapical and occlusal films combined is $29.71 for general practitioners and $35.66 for specialists.Radiographs, Intraoral, Periapical

02111 Single film $ 14. 68 $ 17. 6002112 Two films $ 17. 95 $ 21. 5402113 Three films $ 22. 11 $ 26. 5402114 Four films P $ 24. 76 $ 29. 72


Code P General Specialist Limit


Description02115 Five films P $ 29. 71 $ 35.66

Radiographs, Intraoral, Occlusal

02131 Single film $ 17. 32 $ 20. 7902132 Two films $ 21. 77 $ 26. 12

Radiographs, Intraoral, Bitewing Maximum payable for 2 bitewing films, per patient, per dental treatment provider, per 12 months is $17.95 for general practitioners and $21.54 for specialists.

02141 Single film $ 14. 68 $ 17. 6002142 Two films $ 17. 95 $ 21. 54

Radiographs, Panoramic 1 per 24 months, per patient, per dental treatment provider, per dental office address. Except in an emergency when criteria 1, 2, 5 or 6 applies (see below).These radiographs are covered when required due to:

1) facial trauma with symptoms of possible jaw fracture;2) facial swelling of unknown etiology;3) significant delayed eruption pattern;4) severe gag reflex with multiple cariouslesions;5) diagnosis cannot be made using periapicalfilm; and6) special circumstances clearly substantiatedby thepractitioner.

One of the above criteria (listing the number is acceptable) must appear on the dental claim form for consideration of payment.

02601 Single film $ 34. 69 $ 41. 63

TEST/ANALYSIS HISTOPATHOLOGICAL (Technical Procedure Only)

Test/Analysis, Histological, Soft Tissue (technical procedure only)04311 Biopsy, Soft Oral Tissue - by Puncture + L $ 41. 79 $ 50. 1504312 Biopsy, Soft Oral Tissue - by Incision + L $ 41. 79 $ 50. 15

Test/Analysis, Histological, Hard Tissue (technical procedure only)04321 Biopsy, Hard Oral Tissue - by Puncture + L $ 97. 52 $117.0404322 Biopsy, Hard Oral Tissue - by Incision + L $ 97. 52 $117.04




Description

Preventive ServicesSCALINGScaling and root planing are not routinely covered services - SEE LIMITS.(Note: A unit of time equals 15 minutes)

Maximum of 4 units scaling/root planing per year.

*COVERAGE FOR SCALING/ROOT PLANING WILL BE DETERMINED THROUGH HEALTH DEPARTMENT SCREENING ONLY. NO OTHER SCALING/ROOT PLANING WILL BE APPROVED.

11111 One unit of time * $ 41. 81 $ 50. 1711112 Two units * $ 83. 62 $ 100. 3411113 Three units * $ 125. 43 $ 150. 5111114 Four units * $ 167. 23 $ 200. 6811117 One half unit * $ 20. 90 $ 25. 08




Description

Restorative ServicesWhere at the same sitting in order to conserve tooth structure, separate amalgam/tooth coloured restorations are performed on the same tooth, the fee should be determined by counting the total number of surfaces restored. Maximum allowable for amalgam/tooth coloured restorations is five surfaces per tooth.

No repeat surface (or pins) will be paid more than once in any 12 month period when the subsequent restoration is placed by the same dentist. The amount paid for the previous restoration will be deducted from the amount claimed for the new restoration if performed by the same dentist for the same patient within the 12 month period.

CARIES, TRAUMA AND PAIN CONTROL The final restoration is payable after 7 days have elapsed.

Caries, Trauma and Pain Control (removal of carious lesions or existing restorations or gingivally attached tooth fragment and placement of sedative/protective dressings, includes pulp caps when necessary, as a separate procedure)

20111 First tooth $ 34.83 $ 41.7920119 Each additional tooth, same quadrant $ 34.83 $ 41.79

Caries, Trauma and Pain Control (removal of carious lesions or existing restorations or gingivally attached tooth fragment and placement of sedative/protective dressings, includes pulp caps when necessary and the use of a band for retention and support, as a separate procedure)

20121 First tooth $ 34.83 $ 41.7920129 Each additional tooth, same quadrant $ 34.83 $ 41.79

RESTORATIONS - AMALGAMRestorations, Amalgam, Non-bonded, Retained Primary Teeth21111 One surface $ 27.87 $ 33.4421112 Two surfaces $ 61.03 $ 73.2221113 Three surfaces $ 69.66 $ 83.5921114 Four surfaces $ 83.59 $ 100.3121115 Five surfaces or maximum surfaces per tooth $ 83.59 $ 100.31

Restorations, Amalgam, Bonded, Retained Primary Teeth21121 One surface $ 27.87 $ 33.4421122 Two surfaces $ 61.03 $ 73.2221123 Three surfaces $ 69.66 $ 83.5921124 Four surfaces $ 83.59 $ 100.3121125 Five surfaces or maximum surfaces per tooth $ 83.59 $ 100.31




DescriptionRestorations, Amalgam, Non-bonded, Permanent Bicuspid and Anteriors21211 One surface $ 27. 87 $ 33. 4421212 Two surfaces $ 61. 03 $ 73. 2221213 Three surfaces $ 69. 66 $ 83. 5921214 Four surfaces $ 83. 59 $ 100. 3121215 Five surfaces or maximum surfaces per tooth $ 83. 59 $ 100. 31

Restorations, Amalgam, Non-bonded, Permanent Molars21221 One surface $ 34. 83 $ 41. 7921222 Two surfaces $ 69. 66 $ 83. 5921223 Three surfaces $ 87. 21 $ 104. 6621224 Four surfaces $ 87. 21 $ 104. 6621225 Five surfaces or maximum surfaces per tooth $ 87. 21 $ 104. 66

Restorations, Amalgam, Bonded, Permanent Bicuspid and Anteriors21231 One surface $ 27. 87 $ 33. 4421232 Two surfaces $ 61. 03 $ 73. 2221233 Three surfaces $ 69. 66 $ 83. 5921234 Four surfaces $ 83. 59 $ 100. 3121235 Five surfaces or maximum surfaces per tooth $ 83. 59 $ 100. 31

Restorations, Amalgam, Bonded, Permanent Molars21241 One surface $ 34. 83 $ 41. 7921242 Two surfaces $ 69. 66 $ 83. 5921243 Three surfaces $ 87. 21 $ 104. 6621244 Four surfaces $ 87. 21 $ 104. 6621245 Five surfaces or maximum surfaces per tooth $ 87. 21 $ 104. 66

Retentive PinsPins, Retentive per restoration (for amalgams and tooth coloured restorations) Coverage is limited to 3 pins per permanent tooth, per

patient, per dental treatment provider, per address.

21401 One pin $ 11. 99 $ 14. 4021402 Two pins $ 20. 01 $ 24. 0121403 Three pins $ 26. 69 $ 32. 0221404 Four pins $ 26. 69 $ 32. 0221405 Five pins or more $ 26. 69 $ 32. 02




DescriptionRESTORATIONS - TOOTH COLOURED / PLASTIC WITH / WITHOUT SILVER FILINGS

Restorations, Tooth Coloured Permanent Anteriors Non Bonded Technique23101 One surface $ 48. 75 $ 58.5023102 Two surfaces (continuous) $ 62.70 $ 75.2323103 Three surfaces (continuous) $ 95. 85 $ 115.0223104 Four surfaces (continuous) $ 95.85 $ 115.0223105 Five surfaces or maximum surfaces per tooth $ 107. 27 $ 128.74

Restorations, Permanent Anteriors, Bonded Technique (not to be used for Veneer Applications or Diastema Closure)23111 One surface $ 55. 72 $ 66.8723112 Two surfaces (continuous) $ 69.66 $ 83.5923113 Three surfaces (continuous) $ 104. 48 $ 125.3723114 Four surfaces (continuous) $ 104.48 $ 125.3723115 Five surfaces or maximum surfaces per tooth $ 117. 02 $ 140.42

Restorations, Tooth Coloured/Plastic with/without Silver Filings, Permanent Posteriors, Non Bonded - Permanent Bicuspids23211 One surface $ 48. 75 $ 58.5023212 Two surfaces $ 87.21 $ 104.6623213 Three surfaces $ 95. 85 $ 115.0223214 Four surfaces $ 115.08 $ 138.1123215 Five surfaces or maximum surfaces per tooth $ 115. 08 $ 138.11

Restorations, Tooth Coloured/Plastic with/without Silver Filings, Permanent Posteriors, Non Bonded - Permanent Molars

23221 One surface $ 55. 72 $ 66.8723222 Two surfaces $ 95.85 $ 115.0223223 Three surfaces $ 104. 48 $ 125.3723224 Four surfaces $ 125.38 $ 150.4623225 Five surfaces or maximum surfaces per tooth $ 125. 38 $ 150.46

Restorations, Tooth Coloured, Permanent Posteriors - Bonded Permanent Bicuspids23311 One surface $ 55. 72 $ 66.8723312 Two surfaces $ 95.85 $ 115.0223313 Three surfaces $ 104. 48 $ 125.3723314 Four surfaces $ 125.38 $ 150.4623315 Five surfaces or maximum surfaces per tooth $ 125. 38 $ 150.46




DescriptionRestorations, Tooth Coloured Permanent Posteriors - Bonded Permanent Molars23321 One surface $ 62. 70 $ 75. 2323322 Two surfaces $ 104. 48 $ 125. 3723323 Three surfaces $ 113. 12 $ 135. 7423324 Four surfaces $ 135. 98 $ 163. 1623325 Five surfaces or maximum surfaces per tooth $ 135. 98 $ 163. 16

Restorations, Tooth Coloured, Retained Primary Anterior Non Bonded23401 One surface $ 48. 75 $ 58. 5023402 Two surfaces (continuous) $ 62. 70 $ 75. 2323403 Three surfaces (continuous) $ 87. 21 $ 104. 6623404 Four surfaces (continuous) $ 87. 21 $ 104. 6623405 Five surfaces or maximum surfaces per tooth $ 87. 21 $ 104. 66

Restorations, Tooth Coloured, Retained Primary Anterior, Bonded Technique23411 One surface $ 55. 72 $ 66. 8723412 Two surfaces (continuous) $ 69. 66 $ 83. 5923413 Three surfaces (continuous) $ 95. 85 $ 115. 0223414 Four surfaces (continuous) $ 95. 85 $ 115. 0223415 Five surfaces or maximum surfaces per tooth $ 95. 85 $ 115. 02

Restorations, Tooth Coloured/Plastic with/without Silver Filings, Retained Primary Posterior, Non Bonded23501 One surface $ 48. 75 $ 58. 5023502 Two surfaces $ 87. 21 $ 104. 6623503 Three surfaces $ 95. 85 $ 115. 0223504 Four surfaces $ 104. 48 $ 125. 3723505 Five surfaces or maximum surfaces per tooth $ 104. 48 $ 125. 37

Restorations, Tooth Coloured/Plastic, Retained Primary Posterior, Bonded Technique23511 One surface $ 55. 72 $ 66. 8723512 Two surfaces $ 95. 85 $ 115. 0223513 Three surfaces $ 104. 48 $ 125. 3723514 Four surfaces $ 104. 48 $ 125. 3723515 Five surfaces or maximum surfaces per tooth $ 104. 48 $ 125. 37




Description

Crowns, Single Units27211 Crown, Porcelain/Ceramic Fused to Metal Base +L P $ 497. 34 $ 596. 80 Maximun of 3 crowns per five years.

Limit of one crown, per tooth, per lifetimeA letter of expertise and radiograph must accompany pre-determination

27301 Full, Cast Metal + L P $ 409. 23 $ 491. 08

29101 Recementation / Rebonding of Inlay / Onlay / Crown + L $ 46. 35 $ 55. 62 Maximum coverage for code 29101 is 2 times per year without pre-determination.




Description

EndodonticsPULPOTOMY Maximum payable equals root canal therapy minus

pulpectomy/pulpotomy, if completed within three months by the same dental treatment provider.

Pulpotomy, Permanent Teeth (as a separate emergency procedure)32221 Anterior and Bicuspid Teeth $ 69.66 $ 83.5932222 Molar Teeth $ 125.38 $ 150.46

PULPECTOMY Maximum payable equals root canal therapy minus pulpectomy/pulpotomy, if completed within three months by the same dental treatment provider.

(An emergency procedure and/or as a pre-emptive phase to the preparation of the root canal system for obturation)

Pulpectomy, Permanent Teeth/Retained Primary Teeth32311 One canal $ 69.66 $ 83.5932312 Two canals $ 83.59 $ 100.3132313 Three canals $ 125.38 $ 150.4632314 Four canals $ 150.34 $ 180.40

ROOT CANAL THERAPYTo include: treatment plan, clinical procedures (i.e. pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs, excluding final restoration.

Limit of 3 root canal procedures per five years.

Limit of one root canal procedure, per tooth, per lifetime.

Maximum payable equals root canal therapy minus pulpectomy/pulpotomy, if completed within three months by the same dental treatment provider.

Root Canals, Permanent Teeth / Retained Primary Teeth, One Canal33111 One canal P $ 278.73 $ 334.47

Root Canals, Permanent Teeth / Retained Primary Teeth, Two Canals

33121 Two canals P $ 348.41 $ 418.09

Root Canals, Permanent Teeth / Retained Primary Teeth, Three Canals

33131 Three canals P $ 543.52 $ 652.21

Root Canals, Permanent Teeth / Retained Primary Teeth, Four or More Canals

33141 Four or more canals P $ 627.14 $ 752.55




Description

Periodontal Services

PERIODONTAL ABSCESSThis may include one or more of the following procedures: Lancing, Scaling, Curettage, Surgery or Medication (Note: One unit of time equals 15 minutes)

Maximum of 2 units per year

42831 One unit of time $ 41.81 $ 50.1742832 Two units $ 83.62 $ 100.34

ROOT PLANING, PERIODONTALScaling and root planing are not routinely covered services - SEE LIMITS.(Note: A unit of time equals 15 minutes)

Maximum of 4 units scaling/root planing per year.*COVERAGE FOR SCALING/ROOT PLANING WILL BE DETERMINED THROUGH HEALTH DEPARTMENT SCREENING ONLY. NO OTHER SCALING/ROOT PLANING WILL BE APPROVED.

43421 One unit of time * $ 41.81 $ 50.1743422 Two units * $ 83.62 $ 100.3443423 Three units * $ 125.43 $ 150.5143424 Four units * $ 167.23 $ 200.6843427 One half unit * $ 20.90 $ 25.09

Prosthodontic ServicesA copy of the laboratory invoice or receipt of payment must be submitted for payment of laboratory fee code 99111

DENTURES, COMPLETETo include: impressions, initial and final jaw relation records, try-in evaluation and check records, insertion and adjustments, including three months post insertion care.

Limit of one new denture per arch per 5 years.

Dentures, Complete, Standard51101 Maxillary + L P $ 520.05 $ 624.0651102 Mandibular + L P $ 643.70 $ 772.4451104 Liners, Processed, Resilient in addition to above P $ 137.94 $ 165.53

Dentures, Surgical, Standard (Immediate) (Includes first tissue conditioner, but not a processed reline.)51301 Maxillary +L P $ 597.72 $ 717.26

51302 Mandibular + L P $ 735.66 $ 882.79




DescriptionDentures, Complete, Provisional51601 Maxillary +L P $ 250.92 $ 301.1051602 Mandibular +L P $ 334.57 $ 401.47

Dentures, Complete, Provisional, Surgical (Immediate) (Includes first tissue conditioner but not a processed reline.)51611 Maxillary +L P $ 543.68 $ 652.4151612 Mandibular +L P $ 669.13 $ 802.96

DENTURES, PARTIAL, ACRYLIC Limit of one new denture per arch per 5 years.

Dentures, Partial, Acrylic Base (Provisional) (With or Without Clasps)

52101 Maxillary + L P $ 209.10 $ 250.9252102 Mandibular + L P $ 209.10 $ 250.92

Dentures, Partial, Acrylic Base (Immediate) (Includes first tissue conditioner, but not a processed reline.)

52111 Maxillary + L P $ 250.92 $ 301.1052112 Mandibular + L P $ 250.92 $ 301. 10

Dentures, Partial, Acrylic Base (Immediate) Provisional (with or without clasps) (Includes first tissue conditioner, but not a processed reline.)

52121 Maxillary + L P $ 250.92 $ 301. 1052122 Mandibular + L P $ 250.92 $ 301.10

Dentures, Partial, Acrylic, Resilient Retainer


Dentures, Partial, Acrylic, Resilient Retainer (Immediate) (Includes first tissue conditioner, but not a processed reline.)


Dentures, Partial, Acrylic, with Metal Wrought/Cast Clasps and/or Rests


Dentures, Partial, Acrylic, with Metal Wrought/Cast Clasps and/or Rests (Immediate) (Includes first tissue conditioner, but not a processed reline.)

52311 Maxillary + L P $ 436.79 $ 524.15




Description52312 Mandibular + L P $ 436.79 $ 524. 15

Dentures, Partial, Acrylic, with Metal Wrought Palatal/Lingual Bar and Clasps and/or Rests52401 Maxillary + L P $ 378.21 $ 453.8652402 Mandibular + L P $ 378.21 $ 453.86

Dentures, Partial, Acrylic, with Metal Wrought Palatal/Lingual Bar and Clasps and/or Rests (Immediate) (Includes first tissue conditioner, but not a processed reline.)


DENTURES, PARTIAL, CAST WITH ACRYLIC BASE

Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests Limit of one new denture per arch per 5 years.

53101 Maxillary + L P $ 643.70 $ 772.4453102 Mandibular + L P $ 643.70 $ 772. 4453104 Altered Cast Impression technique in conjunction with 53101 and 53102 + L P $ 91.96 $ 110.35

Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests (Immediate) (Includes first tissue conditioner, but not a processed reline)


Dentures, Partial, Tooth-Borne, Cast Frame/Connector, Clasps and Rests

53201 Maxillary + L P $ 597.72 $ 717.2653202 Mandibular + L P $ 597.72 $ 717.2653205 Unilateral, one piece casting, clasps and pontics + L P $ 209.10 $ 250.92

Dentures, Partial, Tooth-Borne, Cast Frame/Connector, Clasps and Rests, (Immediate) (Includes first tissue conditioner, but not a processed reline)

53211 Maxillary + L P $ 689.68 $ 827.6253212 Mandibular + L P $ 689.68 $ 827.6253215 Unilateral, one piece casting, clasps and pontics + L P $ 250.92 $ 301.10

DENTURES, ADJUSTMENTS If done by provider providing denture, adjustments are only covered 3 months after insertion.

Limit of 4 denture adjustments per arch per year.Denture Adjustments, Partial or Complete Denture, Minor

54201 One unit of time + L $ 39.40 $ 47.28




Description54202 Two units + L $ 78. 87 $ 94.6454209 Each additional unit over two $ 39.40 $ 47.28

Denture Adjustments, Partial or Complete Denture, Remount and Occlusal Equilibration

54301 Maxillary + L $ 118.29 $ 141.9454302 Mandibular + L $ 118. 29 $ 141.94

Denture Adjustments, Complete Denture, With Cast Metal Occlusal Surfaces, Remount and Occlusal Equilibration

54401 Maxillary + L $ 118. 29 $ 141.9454402 Mandibular + L $ 118.29 $ 141.94

Denture Adjustments, Partial Denture, With Cast Metal Occlusal Surfaces, Remount and Occlusal Equilibration


DENTURES, REPAIRS/ADDITIONS Limit of 4 repairs / additions per arch per year.

Denture , Repair, Complete Denture, No Impression Required


Denture, Repair, Complete Denture, Impression Required


Denture , Repair/Additions, Partial Denture, No Impression Required


Denture, Repair/Additions Partial Denture, Impression Required


DENTURES, RELINING (Does not include Remount - see 54000 series) Limit of one reline per arch per 3 years.

Denture, Reline, Direct Complete Denture

56211 Maxillary $ 78.87 $ 94.6456212 Mandibular $ 78. 87 $ 94.64




Description

Denture, Reline, Direct Partial Denture


Denture, Reline, Processed Complete Denture


Denture, Reline, Processed, Partial Denture


Denture, Reline, Processed, Functional Impression Requiring Three Appointments, Complete Denture


Denture, Reline, Processed, Functional Impression Requiring Three Appointments, Partial Denture


DENTURES, REBASING (where the vestibular tissue-contacting surfaces are modified) Limit of one rebase per arch per 3 years.

Dentures, Rebase, Complete Denture


Denture, Rebase, Partial Denture


Denture, Rebase, Complete Denture Processed, Functional Impression Requiring Three Appointments


Denture, Rebase, Partial Denture Processed, Functional Impression Requiring Three Appointments





DescriptionDENTURES, REMAKE Limit of one remake per arch per 5 years.

Denture, Remake, Using Existing Framework, Partial Denture (including articulation)


DENTURES, THERAPEUTIC TISSUE CONDITIONING Limit of 4 procedures per arch per year.

Denture, Therapeutic Tissue Conditioning, per appointment, Complete Denture


Denture, Therapeutic Tissue Conditioning, per appointment, Partial Denture

56521 Maxillary $ 39. 40 $ 47.2856522 Mandibular $ 39.40 $ 47.28

Fixed Prosthodontics66301 Repairs, re-cementation of bridge (+L where incurred during the repair of the bridge) $ 47.28 $ 56.73 Maximum coverage for code 66301 is 2 times per year

without pre-determination.

Oral and Maxillofacial SurgeryFor examination and radiographs, refer to Diagnostic Services.The removal of more than one bicuspid or the removal of more than one 3rd molar at one time, requires confirmation on the dental claim form that the extractions are not for Orthodontic purposes and/or the tooth is symptomatic.

REMOVALS, EXTRACTIONS, ERUPTED TEETH

Removals, Erupted Teeth, Uncomplicated

71101 Single tooth, uncomplicated $ 41.80 $ 50.1571109 Each additional tooth same quadrant, same appointment $ 20. 89 $ 25.07

Removals, Erupted Teeth, Complicated71201 Odontectomy (extraction), erupted tooth, surgical approach requiring surgical flap and/or

sectioning of tooth$ 97. 52 $ 117.04

71209 Each additional tooth, same quadrant $ 97. 52 $ 117.04

REMOVALS, IMPACTIONS, SOFT TISSUE COVERAGE




DescriptionRemovals, Impaction Requiring Incision of Overlaying Soft Tissue and Removal of the Tooth72111 Single tooth $ 97.52 $ 117.0472119 Each additional tooth, same quadrant $ 97.52 $ 117.04

REMOVALS, IMPACTIONS, INVOLVING TISSUE AND/OR BONE COVERAGE




DescriptionRemovals, Impactions, Requiring Incision of Overlaying Soft Tissue, Elevation of a Flap and EITHER Removal of Bone and Tooth OR Sectioning and Removal of Tooth

72211 Single Tooth $ 146.29 $ 175.5472219 Each additional tooth, same quadrant $ 146.29 $ 175.54Removals, Impactions Requiring Incision of Overlaying Soft Tissue, Elevation of a Flap, Removal of Bone AND Sectioning of the Tooth for Removal

72221 Single Tooth $ 195.03 $ 234.0372229 Each additional tooth, same quadrant $ 195.03 $ 234.03Removals, Impactions Requiring Incision of Overlaying Soft Tissue, Elevation of a Flap, Removal of Bone AND/OR Sectioning of the Tooth for Removal AND/OR presents Unusual Difficulties and Circumstances

72231 Single Tooth $ 222.90 $ 267.4772239 Each additional tooth, same quadrant $ 222.90 $ 267.47

REMOVALS, (EXTRACTIONS), RESIDUAL ROOTS

Removals, Residual Roots, Erupted72311 First tooth $ 41.80 $ 50.1572319 Each additional tooth, same quadrant $ 41.79 $ 50.15Removals, Residual Roots, Soft Tissue Coverage72321 First tooth $ 83.59 $ 100.3172329 Each additional tooth, same quadrant $ 83.59 $ 100.31Removals, Residual Roots, Bone Tissue Coverage72331 First tooth $ 97.52 $ 117.0472339 Each additional tooth, same quadrant $ 97.52 $ 117.04

Tobacco-Use Cessation ServicesTo include: Identifying patients who use tobacco, informing patients of oral health consequences associated with tobacco; advising tobacco users to quit; provide appropriate self-help material and discuss treatment options.(Note: A unit of time equals 15 minutes.)

98101 One unit of time

$

33.00 $ 39.60 Maximum of one unit per patient per lifetime.

Pre-determination must include a letter of expertise stating the services being provided.

P $




Description

Laboratory ProceduresThis code is used in conjunction with the "+L" designation following the specific codes in the guide. The addition of these codes are to facilitate computer or manual input for third party claims processing, personal records and statistics, providing one description for a specific procedure code.

When filling out third party claim forms, these codes must follow immediately after the corresponding dental procedure code carried out by the dental treatment provider, so as to correlate the lab expenses with the correct procedures. The following services are only covered when claimed in conjunction with codes which carry the +L designation.

For 99333, please submit in-office laboratory expenses. Laboratory fees must appear immediately below the procedure code(s) to which they apply.

A copy of the Laboratory Invoice, or receipt of laboratory payment, must be submitted with the claim form for Commercial Laboratory Procedures (code 99111).

99111 "+L" Commercial Laboratory Procedures (A commercial laboratory is defined as an independent business which performs laboratory services and bills the dental practices for these services on a case by case basis)

P

99222 Laboratory charges for oral pathology biopsy services when provided in conjunction with surgical services from the 30000 and 70000 code series.

P

99333 "+L" In-Office Laboratory Procedures (an in-office laboratory is defined as a laboratory service(s) performed within the same business entity)

P

99900 Provision of additional personal protective equipment required by the COVID-19 pandemic

$

13.00

$

13.00 Use of regular PPE is not eligible for billing.A flat fee within the fee guides, per appointment.

$ $

dentists - 2021 schedule of dental services and fees for

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